Luận văn Thạc sĩ y học: The perceived quality of healthcare service and patients’ satisfaction in district hospitals, Ulaanbaatar city, Mongolia

THE PERCEIVED QUALITY OF HEALTHCARE
SERVICE AND PATIENTS’ SATISFACTION IN
DISTRICT HOSPITALS, ULAANBAATAR CITY,
MONGOLIA



By:
Chimed-Ochir Odgerel
2010.05.01




Thesis Presented to the Higher Degree Committee of
Ritsumeikan Asia Pacific University, in
Partial Fulfillment of the Requirements for the Degree of
Master of Public Health Management, International Cooperation
Policy

i

ACKNOWLEDGEMENT

First and foremost, I would like to give my most gratitude to my supervisor,
Professor Nader Ghotbi, MD, PhD, for his tremendous support and valuable
guidance. I will always be sincerely grateful for all his kindness, understanding

and great inspiration for my work and student life in Japan. I will remember all
his valuable advice in my future career as I certainly value his professional skill in
the research field.

I also would like to thank Professor Uchida Yasuo for his valuable opinions on
my research and great encouragement.

My wholehearted gratitude goes to JICE (Japanese International Cooperation
Center) because I would not have been here without JICE who selected me as one
of fellowships and provided this opportunity to study in Japan. I would like to
especially thank our JDS (Japanese Development Scholarship) coordinators for
their great support and attentiveness to manage my life in Japan. I am very much
indebted to them.

My honorable appreciation goes to Chimedsuren Ochir, Dean of School of Public
Health, Health Sciences University of Mongolia, and for her valuable opinions on
my research and all her kind support to conduct my research. She supported me to
start my career in the research field.

ii

Last but not least, for my friend Suvdmaa.Ts and my beloved brother
Chinzorig.Ch, thank you very much for help in data collection.


Odgerel Chimed-Ochir

iii

TABLE OF CONTENTS
Acknowledgement i
List of tables vi
List of figures viii
List of abbreviations ix
Abstract x
Chapter one 1
Introduction to the study 1
The goal of the study 4
The objective of the study 4
The research questions of the study 5
The significance of the study 6

The limitations of the study 7
The general structure of the thesis 7
Chapter two 9
The health system in Mongolia 9
The structure of the current health system 9
The financing of health sector in Mongolia 15
The state budget 16
Social health insurance 17
Out of pocket expenses 19
Chapter three 21
Literature review 21
The service quality 21
The quality of healthcare service 22
How to measure the quality of healthcare services? 30
SERVQUAL instrument 33
Chapter 4 37
Methodology of the study 37
Research design 37
The study area 38
Sampling and data collection 38
The validity and reliability of questionnaire 40

iv

Chapter five 49
The results of the study 49
Description of the sample 49
The analysis of SERVQUAL instrument 53
The analysis of patients‘ overall satisfaction 78
Chapter six 102

Discussion of the findings 102
Chapter seven 111
Conclusions and recommendations 111
Conclusions of the study 111
Recommendations 113
Appendix 115
References 120















v

LIST OF TABLES
2.1 Relationship of the Type of Care; and Type of Facilities and Referral level
3.1 Definitions on the service quality
4.1 The estimation of sample sizes
4.2 KMO and Bartlett's Test
4.3 Total Variance Explained

4.4 Rotated Component Matrix
4.5 Factor loading
5.1 Education level of participants
5.2 Occupational status of participants
5.3 Descriptive statistics of Expectations (E) of patients/ Descriptive statistics
of Perceptions (P) of patients
5.4 Mean of SERVQUAL scores
5.5 The first five largest/smallest mean of SERVQUAL scores
5.6 Paired Samples Statistics (total expectations and perceptions of patients)
5.7 Paired Samples Test (total expectations and perceptions of patients)
5.8 Paired Samples Test (difference between expectations and perceptions by
dimensions)
5.9 ANOVA for SERVQUAL scores (by gender)
5.10 Correlations between age and SERVQUAL scores
5.11 ANOVA for SERVQUAL scores (by occupation)
5.12 ANOVA for SERVQUAL scores (by education level)
5.13 ANOVA for SERVQUAL scores (by hospital admitted)

vi

5.14 ANOVA for gap score (by admitted hospital)
5.15 Multiple Comparisons of gap scores (by admitted hospitals)
5.16 ANOVA for SERVQUAL scores (by number of admission)
5.17 ANOVA for perception of patients (by number of admission)
5.18 ANOVA for SERVQUAL scores (by self reported health status)
5.19 Correlations between overall satisfaction and age
5.20 Descriptive of overall satisfaction (by age group)
5.21 Test Statistic for overall satisfaction (by age group)
5.22 Test Statistics for overall satisfaction (by gender)
5.23 Test Statistics for overall satisfaction of patients (by occupation)

5.24 Test Statistics for overall satisfaction of patients
5.25 Test Statistics for overall satisfaction of patients (by admitted hospitals)
5.26 Correlations between number of admission and overall satisfaction
5.27 Test Statistics for overall satisfaction of patients (by number of admission)
5.28 Test Statistics for overall satisfaction of patients (by self reported health
status)
5.29 Correlations between length of stay and overall satisfaction
5.30 Test Statistics for overall satisfaction of patients (by length of stay)
5.31 Test of Parallel Lines (Logit link of Ordinal regression analysis for
complete model)
5.32 Model Fitting Information (Clog-log link of Ordinal regression analysis
for complete model)

vii

5.33 Test of Parallel Lines (Clog-log link of Ordinal regression analysis for
complete model)
5.34 Pseudo R-Square (Clog-log link of Ordinal regression analysis for
complete model)
5.35 Parameter Estimates (Clog-log link of Ordinal regression analysis for
complete model)
5.36 Predicted Response Category * OVSAT Crosstabulation (complete model)
5.37 Model Fitting Information (Clog-log link of Ordinal regression analysis
for parsimonious model)
5.38 Pseudo R-Square (Clog-log link of Ordinal regression analysis for
parsimonious model)
5.39 Test of Parallel Lines (Clog-log link of Ordinal regression analysis for
parsimonious model)
5.40 Parameter Estimates (Clog-log link of Ordinal regression analysis for
parsimonious model)

5.41 Predicted Response Category * OVSAT Crosstabulation (parsimonious
model)
5.42 Correlations between intention to recommend hospitals and overall
satisfaction








viii

LIST OF FIGURES
2.1 Administrative levels of Mongolia
2.2 Sources of health expenditure
3.1 Theoretical framework of study
5.1 Age structure of the participants (by percent)
5.2 Number of admission to the hospital
5.3 Self reported health status at admission (by percent)
5.4 The mean of gap scores
5.5 Q-Q plots of variables on expectations and perceptions of the patients
5.6 Means of expectations and perceptions (by dimensions)
5.7 Gap Score (by dimensions)
5.8 Mean of SERVQUAL scores (by gender)
5.9 Means of SERVQUAL scores (by occupation)
5.10 Means of SERVQUAL scores (by education level)
5.11 Mean of SERVQUAL scores (by hospital admitted)
5.12 Means of SERVQUAL scores (by number of admission)

5.13 Mean of SERVQUAL scores (by self reported health status)
5.14 Frequency of overall patient satisfaction (by percentage)
5.15 Overall satisfaction of patients by gender (by percentage)
5.16 The means of overall satisfaction of patients (by occupation)
5.17 The means of satisfaction (by educational level)
5.18 The means of satisfaction (by hospital admitted)
5.19 Means of satisfaction (by group of number of admission)


ix

LIST OF ABBREVIATIONS
ADB- Asian Development Bank
ANOVA- Analysis of Variance
FGP- Family Group Practice
GDP- Gross Domestic Product
HSDP- Health Sector Development Project
JDS- Japanese Development Scholarship
JICE- Japanese International Cooperation Center
KMO- Kaiser-Meyer-Olkin
MoH- Ministry of Health
SD- Standard Deviation
SERVQUAL- Service Quality
UB- Ulaanbaatar
USA- United States of America

x

ABSTRACT
The perceived quality is defined as ―a gap between patient‘s expectation and
perception of service along the quality dimensions‖ (Parasuraman et al., 1985).
The patients‘ perceptions seem to be largely ignored by healthcare providers in
Mongolia. Thefore, this study is a patient-centered one and focuses on examining
service quality indicated by differences of patients‘ expectations and perceptions
in the district hospitals of Ulaanbaatar city, Mongolia. It also examines the link
between patients‘ perception and their overall satisfaction with healthcare services.
A hundred and fifty seven (157) patients were interviewed using a SERVQUAL
(Service quality) questionnaire proposed by Parasuraman (1985; 1991).
According to the factor analysis, all questions were loaded into seven dimensions
including tangible, reliability, responsiveness, communication, empathy,
accountability and assurance.
The perceived service quality was measured by the following equation:
Q= Px-Ex

Where: Q – is Perceived quality of service; and Px and Ex – are ratings
corresponding to perceptions and expectations of ―x‖ statement. The ordinal
regression model was used to examine significant elements influencing patients‘
overall satisfaction.
The analysis shows that expectations of the patients are higher than their
perceptions and it suggests that there is a room for quality improvement initiatives

in all seven dimensions. The largest quality gaps are in the empathy dimension
including elements on nursing care, and respect shown by doctors and nurses

xi

towards patients. The neat appearance of doctors and staff presents a less
problematic element of the service quality in district hospitals.
Generally, patients have high expectations on all dimensions of quality of
healthcare services. Among the seven quality dimensions, assurance factor
including the competency of the doctors and nurses‘ skill shows the highest
expectation and perception.
Patients‘ evaluations also suggest that they are disappointed regarding the quality
of healthcare services in relation to care provided by nurses and respect shown by
doctors and nurses. These elements are also included in the empathy dimension.
The patients have low perceptions on comfortableness of patients‘ rooms and
availability of modern equipment in district hospitals.
Patients who had been admitted in hospital for the first time were less satisfied
with services while those who had been admitted more than 12 times were more
satisfied. Any other background factors of patients were not found to be
significantly related to their satisfaction. The overall satisfaction of the patients
was significantly associated with six explanatory variables regarding perception
of patients: comfortableness of patients‘ room (p=0.007), explanation of
procedure done by nurses (p=0.003), helpfulness of nurses (p<0.001),
respectfulness of nurses (p=0.008), nurses‘ care (p=0.004), and attentiveness of
doctors to listen to patients (p=0.016).
In the discussion on the findings of the study, it is suggested that the level of
doctors‘ competence and nurses‘ skill should not be neglected by hospital
managers solely relying on the patients‘ high perception because patients‘

xii

judgment might not be objective due to their lack of knowledge on medical issues
and unfamiliarity with medical service. However, healthcare providers need to
pay attention to more patient-centered empathetic service. The regular feedback
from patients can be integrated in the healthcare delivery system and the quality
of healthcare service can be effectively monitored through patients‘ voice to bring
improvements in behaviors of the doctor and nurses.
The current findings provide a guideline for the healthcare provider in the
allocation of efforts to maximize patient satisfaction and to improve the perceived
quality of healthcare services.









1

CHAPTER ONE
INTRODUCTION TO THE STUDY
Keeping pace with current technological advances, people today are choosing a
new approach to healthcare services; they are well informed and eager to take
responsibility for their own health. Therefore, the consumers of healthcare
services have exceptionally higher expectations and demand a high level of
accuracy, reliability, responsiveness and empathy. In short, they demand overall
better healthcare services than in the past. They are also becoming more critical of
the quality of healthcare service they are provided with (Lim & Nelson, 2000).

Due to this new paradigm in healthcare services, hospital administrators need to
take into consideration patients‘ expectations and perceptions, and must address
the issue of improving the perceived quality of healthcare services they provide.
In general, providing good quality healthcare is an ethical obligation of all
healthcare providers (Zineldin, 2006) and receiving good quality care is a right of
all patients (Pickering, 1991).
Until 1990 Mongolia was under a central planned economy and healthcare
expenditure was fully financed by the government. In the central budget
dependent health system, the technical aspects of quality such as appropriateness
of diagnoses and treatments was the priority issue of quality of healthcare service.
In other words, the quality of healthcare services was solely defined by provider
based approach. However, upon the reform of the health system in late 1990s, the
concept of patient oriented services was incorporated. In spite of this change, the
quality assurance system still focuses its attention on the technical aspects of care

2

rather than aspects of interpersonal quality such as communication with patients,
willingness to help patients, timeliness and accuracy of services. For instance, a
government agency, State Professional Inspection Agency, is in a charge of the
monitoring and implementation of regulations and standards related to health
system and is responsible for ensuring whether or not the health facilities and staff
follow the standards (Bolormaa et al., 2007). The Agency audits hospitals every
six months and is entitled to give penalties, even to revoke a license, if there is
evidence that medical personnel at a hospital do not follow standards; however,
no incentives are given to good interpersonal care provided by healthcare
providers. Thus the medical staffs are more cautious about not making technical
mistakes in their duties instead of being cautious about improving their
interpersonal relationship with patients.
According to the report of the Ministry of Health of Mongolia (MoH) (2006),

―Traditional patient complaint modes, such as phone calls and letters, still
predominate in the health sector‖. Although these arrangements tend to be
considered effective, in fact, patients‘ perceptions were ignored by health
administrators as well as health providers and the quality of day-to-day care
remains very low; bureaucracy of medical staff, poor communication and other
aspects of interpersonal care are widely criticized (Bolormaa et al., 2007). In late
1990s, patient satisfaction was considered as a major criterion of the quality,
although, the findings have not been reflected in improving the quality of
healthcare service. Moreover, neither clear guidelines nor sector-wide approaches
for this issue have been developed. Misunderstanding of patients‘ needs leads to

3

the underutilization of existing facilities and hinders the overall development of
the health system. Therefore, it is important to consider the patients‘ opinion to
assess the quality of healthcare services.
The district hospitals which are the target hospitals of my study provide healthcare
services to the whole population of Ulaanbaatar city, the capital city of Mongolia;
however, district hospitals can‘t play a gate keeping role in inpatients service.
Thus, it results in an overload of the next higher level hospitals.
In 2008, 81.7% of health expenditure was spent for inpatient service. Even though
the rate of bypassing district hospitals is high, the average occupancy rate in
district hospital is still very high. It might show that many unnecessary cases
which can be treated at home are admitted in district hospitals in order to fully
occupy the beds. If we can pay more attention towards the quality of healthcare
services provided in district hospital, the bypassing rate might be decreased and
following that, the number of unnecessary cases admitted in district hospital also
can be decreased. Consequently, the health expenditure on inpatient services can
be reduced and overall, the hospital system can be managed effectively.
Taking into account of situations which have been previously mentioned, an

examination of the quality of healthcare services provided in district hospitals
could be a good start for an effective management of the admission system and
patient oriented service. Therefore, my study focused in examining the perceived
quality of healthcare services provided in the district hospitals of UB city,
Mongolia,


4

The goal of the study

The main goal of this research is to study the perceived quality of healthcare
services and the relationship between the perception and satisfaction of patients
with healthcare services provided at the district hospitals of Ulaanbaatar city,
Mongolia

The objective of the study

In order to achieve the goal of the study the following objectives were developed:
1. To assess the patients‘ perceptions and expectations on the quality of
healthcare services provided by the district hospitals of UB city, Mongolia
2. To examine how closely patients‘ perceptions and expectations match
(quality gap) in each quality dimensions; and to study if there are any
factors influencing patients‘ perceptions and expectations.
3. To examine the significant elements of patients‘ perceptions influencing
the patients‘ overall satisfaction with healthcare services provided at
district hospitals
4. To assure about the relationship between the patients‘ satisfaction and
their intention on recommendation of the hospital to others

5

Within the goal of the study, three main hypotheses can be proposed as follows:

1. In general, patients have high expectations and lower perceptions
regarding healthcare services, however, large variation can be found in
terms of quality dimensions.
2. The quality gaps exist in all quality dimensions in district hospitals;
however, size of gaps can differ.
3. Generally, patients are satisfied with inpatient care provided in district
hospitals; however, a certain number of elements can significantly
influence their overall satisfaction.

The research questions of the study

In order to achieve the research objectives and check proposed hypotheses the
following research questions were raised:
1. Which elements of quality of healthcare services are highly/lowly
expected by patients who were admitted in district hospitals?
2. Which elements of quality of healthcare services are highly/lowly
perceived by patients admitted in district hospitals?
3. Is there any difference between patients‘ expectations and perceptions on
all dimensions (tangibility, reliability, responsiveness, communication,
empathy, accountability and assurance) of quality of healthcare service
offered by district hospitals?

6

4. Which elements and dimensions of quality of healthcare services showed
the largest/smallest gap between the patients‘ perceptions and expectations?
5. How far do patients‘ expectations and perceptions depend on their
background factors including age, gender, occupation and other factors
such as the number of admissions, length of stay and self reported health
status?
6. Which elements of patients‘ perceptions significantly influence the
patients‘ overall satisfaction?
7. How far does patients‘ satisfaction depend on their background factors
including age, gender, occupation and other factors such as the number of
admissions, length of stay and self reported health status?
8. Is there any relationship between patients‘ overall satisfaction and their
intention on recommendation of hospital to others?

The significance of the study

The current research may help healthcare providers to understand customer‘s
preferences by measuring the service quality through its dimensions. The
hospitals could use this instrument to collect data about their patients‘ perceptions
in order to make strategic decisions.
This research also will share the gathered information with healthcare providers
and stakeholders in health sector as an input for the improvement of perceived
quality of healthcare services offered in the district hospitals of Ulaanbaatar city,
Mongolia.

7

The limitations of the study

-Given the time constraint, the study covered only 3 district hospitals out of 9;
however, they might be good representatives of district hospitals in Ulaanbaatar
city in terms of the socio-economic status of the population in catchment areas.
-The study is mainly based on a quantitative analysis of the results. A qualitative
study such as focus group discussion and individual interview was not conducted
due to the time limitation.

The general structure of the thesis

The thesis consists of seven chapters and the first part of this study, chapter 1,
Introduction of the study, provides a rationale for the study. It also includes the
goal and objectives of the study as well as the research questions. Furthermore,
this chapter explains the limitations and the significance of the research.
Chapter 2, the health system of Mongolia, briefly introduces the current health
system of Mongolia and financing of health system. This information helps with a
better understanding of the context of the study and its purpose.
Chapter 3, Literature review, provides the theories and concepts used by the
researcher as references, tools or models to explain the main issues regarding the
quality of healthcare services. It also provides the conceptual framework of the
study.
Chapter 4, Methodology of the study, explains and describes the methodology
including selection of the study area, sampling, data collection and structure of the
questionnaire.

8

Chapter 5, Results of the study, introduces the results of data analysis.
Chapter 6, Discussion of findings, discusses the findings of the study based on

results of data analysis.
Chapter 7, the last chapter, provides a conclusion to this study and offers
recommendations to help solve the problems identified in the study.





















9

CHAPTER TWO
THE HEALTH SYSTEM IN MONGOLIA
This chapter briefly introduces the health system of Mongolia including the current
structure and financing of health system.

Until 1990, Mongolia had a Semashko system
1
in which the health system was
fully financed and delivered by the government. Most of the health facilities and
services were maintained from the state budgets and supported by the Soviet Union.
In the early 1990s, the Semashko system was becoming unsustainable because of
the collapse of the Soviet Union and it was obvious that the government was not
able to be fully responsible for the health expenditure by itself. During this process,
the percentage of health expenditure for GDP dramatically decreased from 6.7% in
1990 to 4% in 1992. Moreover, health expenditure per capita decreased from
62.4$ in 1990 to 18.9 $ in 1992. During this period, international organizations and
other donors assisted Mongolia to help compensate for the cease of financial and
social support from the Soviet Union and to establish the current health system of
Mongolia.

The structure of the current health system

Currently, the healthcare service system in Mongolia is characterized by three
levels of healthcare services built on the principle of delivering equitable,


1
A uniform model of organizing health services introduced in CEE/CIS countries after the Second
World War, and abolished in the early 1990s. Financing of health services was entirely through the
state budget, with publicly owned healthcare facilities and publicly provided services. Different
levels of state administration—central, regional, and local—were responsible for planning,
allocation of resources and managing capital expenditures.( Saltman et al., 1998)

10

accessible and quality healthcare services for every person. This health system is
organized according to the administrative divisions as shown in the figure 2.1.
The country has 21 provinces (aimag) and 334 sub provinces called a soum
(Ministry of Health, 2008). Each soum is administratively divided into four to six
bagh which is the smallest administrative unit in rural areas. Ulaanbaatar, the
capital city of Mongolia, is divided into nine urban districts; each district is
subdivided into varying numbers of urban subdistricts named as a khoroo
depending on the population of each district.

Figure 2.1. Administrative levels of Mongolia

1550 baghs /the smallest unit in province/
334 soums /subprovince, rural area/
21 aimags /Provinces/
121 khoroo /subdistricts/
9 districts /urban area/
Ulaanbaatar, Capital city
Central Government



Primary health care is provided by family doctors in a family clinic which is
officially named as a family group practice (FGP) in Mongolia. In addition to that,
soum and inetrsoum hospitals provide primary health care at aimag level.
From the end of 1990s, MOH of Mongolia started implementing the Health Sector
Development Project (HSDP) with the assistance of Asian Development Bank
(ADB) and established FGPs in Ulaanbaatar city and in all aimags. Each khoroo
has one or two FGPs depending on the size of population of khoroo. FGPs

11

usually consist of three to six family doctors and totally, as of 2008, there were
228 FGPs, 125 of them provided primary healthcare services to 1,034,700
residents in UB city and 103 served residents of 21 aimag centers. 2142 health
professionals including 794 doctors and 748 nurses and other health workers were
providing primary healthcare to residents in country (Ministry of Health &
National Center for Health Development, 2008). On average, each FGP provides
primary healthcare for 6375 residents and the number of residents per family
doctor ranges from 1200-1500 (Ministry of Health & National Center for Health
Development, 2006). The Ministry of Health set up a package of services called
the essential package of service to be provided at FGPs in 2002 in accordance
with Order N 306 of Minister of Health. The services provided by family
physicians include outpatient exams, antenatal care, the prescription of essential
drugs, counseling, home visits, palliative care and public health activities such as
family planning and health education for population.
They should serve a critical gate-keeping role. As a part of the gate-keeping
function, FGPs is the first contact with health service and they refer patients to the
next higher-level facilities (district hospital) for specialised care. However, there
is a problem of bypassing the FGPs and patients are going to a higher level of
healthcare facilities by themselves.
According to the study of Orgil.B (2003) (as cited in Bolormaa, 2007), the
primary health care utilization by the registered population reached 71-82 percent
in the urban area; however, the effectiveness of primary healthcare is still
problematic.

12

There are some differences between the provision of primary care services in
urban and rural areas in terms of funding, functions and types of provider. Soum
and inetrsoum hospitals are responsible for the provision of primary healthcare in

soum level while in bagh level, services are provided by physician assistants
called feldsher. In rural areas, the population is sparsely distributed over a large
area and therefore, in order to improve access to healthcare services the primary
healthcare facilities (soum and intersoum hospitals) also provide some inpatient
service apart from outpatient service. Soum and intersoum hospitals have an
average of 15-30 beds. The antenatal and postnatal care, normal deliveries, minor
surgeries, and immunization activities are included in services provided by
primary healthcare facilities in rural area.
In aimag level, the FGPs provide primary healthcare.
Generally, the establishment of FGP was the foundation of the development of
sustainable primary healthcare in Mongolia; however, there are still issues
including improvement of the quality of services and reducing the high level of
self referrals to the next higher level of healthcare facilities.
At the secondary level, healthcare is provided by district hospitals in UB city.
There are 9 district hospitals in UB city and the average number of beds in district
hospitals is 225. The district hospitals provide all specialized care through the
outpatient services. They also provide inpatient services for some specialties
including internal medicine, pediatrics, neurology and emergency care. Moreover,
maternity services are delivered by three Maternity hospitals in UB city and are